Written by Dr Daniel Roberts, ST6 Emergency Medicine, Brighton

Edited by Frankie Cackett

The advert seemed to have my name written all over it. Teaching the use of point of care ultrasound (PoCUS) in a low resource setting slotted in perfectly with experience of one each of a previous ultrasound and teaching fellowship as well as time spent in another low resource setting (Sudan with MSF)

Freetown, so named as it became a home for freed enslaved people in the 1700s, accounts for 40% of Sierra Leone’s urban population, with over one million residents. Following the 2014-2016 Ebola outbreak, which saw 14, 124 cases in Sierra Leone, the leading cause of deaths as of 2019 remains lower respiratory tract infections. This is closely followed by malaria, although new cases have been declining since 2020. Whilst there has been an increase in doctors in the country since 2011, the density remains one of the lowest on the continent with the density of other healthcare professionals including nurses, pharmacists and dentists in decline. King’s has been working in the main public hospital in Freetown for around a decade, mainly working in bilaterally stand-alone projects, for example introducing clinical early warning scores and antimicrobial stewardship. My role was to try to implement PoCUS into Freetown’s emergency department. As in many countries, Emergency Medicine (EM) isn’t (yet) a speciality in Sierra Leone. Instead, the new arrivals area is run by the family medicine team (a “GP plus” model which exists in many African countries), and in the evenings by an on-call junior doctor.

With regards to imaging, the hospital had access to plain radiographs, which, remarkably,  is more than what 60% of the global population has access to. More specialist radiological investigations could be performed off site with private providers, often at great expense and great difficulty with a patient in extremis.

This is where PoCUS was thought to play a potential role.  It has been used for years by emergency clinicians to get quick and useful additional information without the time and logistics of sending a patient to a radiology department. There has long been a model curriculum for this, outlined by the International Federation of Emergency Medicine. With progress in ultrasound technology a single probe can now image heart, lung, abdomen and visualise structures during needle guided procedures. It did, therefore, seem like a great time to get involved in the King’s partnership project, working with local colleagues in understanding how best to utilise this imaging modality in Freetown.  

In addition to conditions commonly seen in the UK, POCUS in Freetown could be used to image pathology that was much less familiar to myself, such as unilateral pulmonary effusions due to tuberculosis (TB), frank pus in the abdomen secondary to perforated viscus and pericardial effusions (more TB). The programme planned to teach a few clinicians how to identify these common local conditions, then have them cascade this knowledge to their colleagues. This would allow for faster diagnostics, and ultimately more timely treatment for the most unwell patients in the emergency department. 

First, I had to meet various department heads and ministry officials: partnership projects involve lots of buy-in from various big stakeholders. After an initial slow few weeks of meetings, I was excited to start teaching. To my surprise, following an encouraging attendance at the introductory talks, the numbers of trainees attending the practical sessions quickly dwindled. 

Trying everything I could think of to engage those whose initial interest I had piqued- flexible sessions, evening sessions, week-end sessions and drop-in sessions to no avail, I started talking to department heads, the juniors, and project managers to try and ascertain what exactly had happened. Towards the end of my time in Sierra Leone this led to rolling out the teaching in a district hospital much earlier than initially planned, to seek better and more sustained engagement. 

There hadn’t been zero success in the tertiary hospital. A medical officer from the family medicine team quickly became an ultrasound expert, asking me many questions I couldn’t answer and had to refer on to more experienced colleagues. Meanwhile, another is still sending me interesting case videos many months later. In a few patient journeys, we made treatment altering diagnoses with our new skill. On a personal level I learnt not only more practical ultrasound skills, but broader communication and interpersonal skills, as well as vastly expanding my teaching repertoire: designing a teaching programme from scratch is a steep learning curve. 

Fundamentally though, there was a huge disconnect between our advancing diagnostic skills and our ability to provide treatment for these conditions. A multitude of factors played into this. Patient factors included delayed presentation or limited finances. More significantly, systemic factors ranged from limited capacity for emergency care in small departments, challenges in implementing a training programme outside of the formal curriculum, to an unreliable electricity supply or the impact of hot and humid weather on ultrasound machinery. 

These factors all played a role in my own very difficult decision to leave the project early. The project itself is continuing with my replacement colleague, and I sincerely hope it continues to progress and surmounts more and more of the challenges. King’s continue to implement other projects, with the continued focus on voluntary posts which aim to improve emergency care in Sierra Leone, and hopefully the first step on the road to a dedicated EM specialty. 

Reflecting on my experiences, long-term resource and time investment in one location is needed to really effect lasting change and improve emergency care in Sierra Leone. For now, my own journey will be on the road I’m more familiar with as an EM trainee, with its own challenges as we manage the sickest patients in the hospital whilst surrounded by chaos!